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    External Auditory Canal Transillumination-Guided Middle Fossa Approaches: An Anatomical Feasibility Study
    (Lippincott Williams and Wilkins, 2025) Şahin, Mustafa; Güngör, Abuzer; Doǧruel, Yücel; Luzzi, Sabino; Yılmaz, Adem; Türe, Uğur
    BACKGROUND AND OBJECTIVES: The middle fossa approaches are tremendously versatile for treating small vestibular schwannomas, selected petroclival meningiomas, midbasilar trunk aneurysms, and lesions of the petrous bone. Our aim was to localize the internal acoustic canal and safely drill the petrous apex with these approaches. This study demonstrates a new method to locate the internal acoustic canal during surgery in the middle fossa. METHODS: The microsurgical anatomy of the middle fossa floor was studied in 11 formalin-fixed and silicone-injected cadaveric heads. Extradural dissection of the skull base was completed from the posterior to the anterior side. A zero-degree rigid endoscope was inserted perpendicularly into the external auditory canal. The light beam was first directed through the tympanic membrane, avoiding injury to the tympanic membrane. The room lights were dimmed to provide a clearer view of the transilluminated bony area. Drilling was performed with transillumination guidance. RESULTS: The transilluminated area included the tympanic and mastoid tegmen up to the arcuate eminence. The nonilluminated area was bounded posteriorly by the arcuate eminence, laterally by the greater superficial petrosal nerve, and posteromedially by the petrous ridge. In all specimens, drilling the transition line between the Kawase triangle and the transilluminated area unroofed the internal auditory canal (IAC). No transillumination of the carotid canal was seen after anterior petrosectomy in any of the specimens. The entire contents of the IAC were preserved in both anterior petrosectomy and unroofing of the IAC. CONCLUSION: In this anatomical study, transillumination of the external auditory canal proved to be feasible, accurate, and safe in guiding the middle fossa approaches. The ease of implementation and cost-effectiveness of the technique may suggest a possible application in operative scenarios. © Congress of Neurological Surgeons 2025. All rights reserved.
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    Microsurgical Resection of a PediatricTegmentum Tumor Through the Paramedian Supracerebellar Transtentorial Approach with the Tentorial Cut Technique: 2-Dimensional Operative Video
    (Lippincott Williams and Wilkins, 2024) Rahmanov, Serdar; Doǧruel, Yücel; Güngör, Abuzer; Türe, Uǧur
    The brainstem contains a highly complex group of nuclei and major white matter tracts within a small volume.1 The complex nature of its anatomy creates challenges for surgery in this area, impeding the standardization of approaches. Therefore, the concept of the "safe entry zone" should be considered with caution, and the strategy for each patient should be tailored based on the relevant subunit of the brainstem and individual patient characteristics. The critical parameter to target in patients is achieving the highest possible extent of resection while preserving function.1 The paramedian supracerebellar transtentorial approach is usually suitable for midbrain lesions. This approach allows for targeting tegmental tumors through the posterolateral midbrain surface.1 It is typically performed through a paramedian suboccipital craniotomy, ideally with the patient in the semisitting position, and is now considered a standard and safe approach.2 In patients with a spontaneous atrial right-to-left shunt, lateral or semilateral positions are viable alternatives, with the semilateral preferred for intraoperative magnetic resonance imaging.1 The cerebellar hemispheric tentorial bridging veins are usually located in the surgical route, narrowing the surgical corridor.3 Sacrifice or unintended rupture of these veins can sometimes lead to unexpected serious complications. Therefore, it is essential to preserve these veins during supracerebellar approaches.3 In this study, we demonstrate the resection of a pediatric tegmentum tumor through the left-sided paramedian supracerebellar transtentorial approach. In addition, we show the tentorial cut technique used to preserve the cerebellar hemispheric tentorial bridging veins. The patient's parents consented to the procedure and to the publication of his image. © 2024 Lippincott Williams and Wilkins. All rights reserved.
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    Sublabial transmaxillary approach to the inferior aspect of the orbit
    (American Association of Neurological Surgeons, 2025) Doǧruel, Yücel; Güngör, Abuzer; Türe, Hatice; Türe, Uǧur
    OBJECTIVE The objective was to demonstrate the surgical steps and outcomes of the sublabial transmaxillary microsurgical approach with endoscopic assistance to treat lesions in the inferior aspect of the orbit, as well as to describe the use of patient-specific 3D models to facilitate surgical preparation and improve experience with the technique. METHODS The authors' study evaluated data from patients who underwent an endoscope-assisted sublabial transmaxillary approach for inferior orbital lesions. For 2 patients, 3D models were created for preoperative planning and assessment of the approach. Surgical steps comprised osteotomy to access the maxillary sinus, bony resection of the orbital floor, opening of the periorbital fascia, and dissecting and removing the lesion, followed by closure. The neuroendoscope was used to inspect the surgical cavity between each step. RESULTS The study included 5 patients with varying visual field defects and proptosis who underwent the sublabial transmaxillary microsurgical approach with endoscopic assistance. Complete resection was achieved in all, and all patients reported improvement in visual field defects and proptosis after the procedure. No complications were observed except for transient unilateral maxillary edema noted around the incision site in 3 patients during the early postoperative period, which resolved within a few days. Histopathological examination confirmed the diagnosis of cavernous malformation in all patients. CONCLUSIONS The sublabial transmaxillary approach is a direct and safe method to resect cavernous malformations at the inferior aspect of the orbit. It reduces the risk of complications associated with lateral, transcranial, and transnasal approaches that may cross critical structures. The microsurgical approach provides the benefit of two-handed dissection for lesions embedded in orbital fat, which can be challenging because of adhesions to surrounding tissues. The use of 3D models can facilitate surgical planning and enhance familiarity with the approach. © AANS 2025.